What Stage Is It?

Staging and Fitness Tests

The cancerous lump
What stage is it?

Once breast cancer is confirmed, we wish to know how much it has spread in the body. The lesser it has spread, the earlier is the stage. And earlier stages have a better outcome than later stages. This article is a little long, but I assure you, it will help you understand better. Please read on.

What exactly does 'spread elsewhere' mean?

The cells of a cancer are very 'loose'. And unlike, normal cells in the body, even a single cancer cell can keep multiplying non stop, wherever it may be. When a cancer is small, the number of cells is less and they remain 'clumped' together. But as the tumour grows, some of these 'loose' cells will disconnect from the tumour and the moment they come near lymphatic channel or blood vessel, they will enter it and go somewhere else and start multiplying there. The common organs to which a cancer cell can reach and multiply are - liver, lungs, bone and brain.

Breast cancer, of course, begins in the breast. Initially, it is a very small tumour, of the size of a 'grain of sand' (maybe a few millimeters) . Such small tumours usually do not spread. But slowly, over months or years, the tumour grows. First, usually, some cells may enter the 'lymph' and reach some lymph nodes in arm pit. But this is still treatable, as we can remove the tumour and the nodes in arm pit by surgery. The moment a cancer cell enters blood, it can just go anywere - liver, lung etc. It has been found, that as the size goes on increasing every centimetre above 1 centimetre, the chance that the tumour cells may be in the blood also keeps on increasing. But it's just not predictable. It depends on the type of tumour also. Sometimes, smaller tumours would have spread while larger ones wouldn't have.

Hence, in cancer patients, we do these staging tests, to find out if the breast cancer has reached the liver, lungs, bone, nodes and a few others places.

But how does this staging matter?

If cancer is limited to the breast and nodes in arm pit (and has not spread anywhere else), we can operate and remove those areas and give a good chance for a cure
If cancer has spread beyond the breast and nodes, to the liver, lungs, bones or other palces, surgery has no role and chance of cure is much less.

I counsel the above to my patients, and suggest them to undergo two different sets of tests, both of which will influence the treatment decisions. The tests are as follows:

Staging tests : To assess if the cancer is limited to the breast only or has it spread elsewhere
Fitness Tests : These are routine tests to tell us how fit the patient is, to undergo cancer treatment

Staging Tests

To decide which test to do for staging of breast cancer, I have to decide based on my rough judgement of stage during the breast examination. If I feel it's an early stage, I may not do a PET CT, but do some other tests. If I feel it's a little more, I might do PET CT. This choice of test varies from patient to patient and from hospital to hospital. Following are two sets of tests, of which one I prescribe:

PET CT: After confirming the blood sugar is less than 150 mg/dl, a dye is injected in the blood. This dye circulates all over the body and is 'taken up' only in areas of increased activity (cancer, some infections). From injection time, about half an hour later, a head to toe scan is done to see where all was the dye 'taken up'. We are expecting it to be taken up in area of breast lump. But apart from that, is there a take up in nodes or liver or lungs, etc. PET CT is the best method of staging
CT Scan and Bone Scan For early stage cancers, a PET CT can be avoided anda simple CT Scan from neck to navel can be done and a separate bone scan can be done

Mammography for breast lumps
Core Biopsy Needle for Breast tumour

Fitness tests

Fitness tests consist of:
Routine Blood Tests - to see Hemoglobin, liver function, kidney function, clotting profile, sugar, thyroid, blood group, vitamin D, viral markers etc. Other blood tests may be added if needed.
Chest X Ray PA View - to assess the lung fields and look for any infection or long standing lung illnesses.
ECG and 2D Echo Cardiogram - ECG gives an idea of the 'electrical' activity of the heart, and can detect any underlying heart problems. 2D Echo gives an idea of contraction and performance of the heart chambers and the valves.

Whether we plan a surgery or chemotherapy, it is these tests which will help us decide whether the patient is fit to undergo the same of not.

So what will the reports show?

The staging test will roughly put the patient into one of the four categories:

Very small tumour, no spread elsewhere
Small tumour (or maybe a bigger tumour), a few small arm pit nodes, no spread elsewhere
Any size tumour, larger arm pit nodes, no spread elsewhere OR larger tumour with skin involvement over the breast
Any size tumour, but has spread elsewhere (liver/ lung / bone)

Depending on the results above, the treatment will be selected. All four above have different approaches. In addition to above, one more thing which will influence the treatment is the fitness tests.

Our Approach at this Step

So, at this point, we are now in complete knowledge of what type of breast cancer the patient has and how much has it spread in the body. We also know how fit is the patient and what treatment will she tolerate. With this information, we can now go to the next section on treatment planning

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Journey of BC: Diagnosis

1. I feel a lump! - The first visit to doctor
2. Is it really cancer? - Confirmatory tests
3. What is the stage? - Staging and fitness tests - You are presently on this page
4. Will it be surgery first? or chemo first? - Treatment planning and sequence

Journey of BC: Surgery

5. Should I conserve or remove breast? - Choice of Surgeries for breast cancer
6. How long will be the surgery? - Admission and Surgery
7. Care after surgery - Precautions and guidelines
8. What next? - The Pathology Report

Journey of BC: Further Treatment

9. How many chemo cycles? - Chemotherapy Consultation
10. Is a PORT necessary? - ChemoPORT insertion
11. Will I be normal during chemo? - The Chemotherapy time
12. Is Radiation painful? - Radiation Therapy
13. Yes!! I did it! - Treatment is over
14. How frequently do I meet doc? - Follow up guidelines

Other Topics

Risk Factors - The Risk Factors for Breast Cancer
Symptoms of Breast Cancer - Know the Symptoms of Breast Cancer
Early Detection of Breast Cancer - The Guidelines

Neo Adjuvant Chemotherapy (NACT) - For LABC
Sentinel Node Biopsy - How is it done?
Targeted Therapy - Trastuzumab
Hormone Therapy - Who gets it?